Fitness Intake Form

Thank you for contacting me! Please fill out this form so I know the best way to help you!

First and last name:

Email Address:

Phone number
###-###-####

What are fitness goals are you wanting to achieve? (Loose 10lbs, gain muscle etc..)

If you want to loose weight, please indicate the approximate amount

5-10 lbs10-20 lbsmore than 20

Are you currently using any protein powder or supplements?

YESNO

If so, what type of protein powders or supplements are you using?

Are you willing to commit to a guided healthy nutrition plan and weekly training tips?

Yes, I am willingNot sureNot at this time

Are you willing to re-direct a portion of your current grocery bill to specific nutritional meals per day that offer a risk free 100% guaranteed money back in the first 30 days?

Yes, I'm willing to reallocate $5.00 per day to reach my goalYes, I'm willing to reallocate $10 per day to reach my goalYes, I'm willing to reallocate $15 per day to reach my goalsYes, I'm willing to reallocate $20 per day to reach my goalsNot at this time

How long are you looking to be coached on a fitness program?

As long as it takes for me to reach my goalsI'm going to see how it goes, month to monthI'm not sure, maybe 6 months